Summary of Key Points
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All patients with injuries to the spinal column will require appropriate nonoperative management during their care.
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The majority of spine fractures can be managed nonoperatively with excellent long-term results.
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Those that require surgical treatment must be initially managed with appropriate, meticulous nonoperative techniques.
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The integrity of the posterior ligamentous complex can be key to deciding on operative versus nonoperative care in the adult patient.
Nonoperative methods have been a mainstay of care for spinal injuries since antiquity. Even with modern-day advanced surgical techniques, the majority of spine injuries should be managed nonoperatively with the goal of healing the spine without any of the inherent risks of surgery. The goal is to restore function and maintain alignment without compromise of stability or loss of neurologic function. In most spine injuries, a good functional outcome and no long-term disability can be expected with nonoperative care.
Nonsurgical treatment is used in all cases of spine injuries. Nonoperative treatment techniques are employed at the initial evaluation and management at the scene of the accident. In the majority of cases, nonsurgical principles are extended as a definitive treatment plan. In addition, during every step of diagnosis and treatment, strict adherence to principles of immobilization must be followed to minimize motion to the injured spine and prevent neurologic injury or deterioration.
The objectives of nonoperative management of spine injuries are the same as those for operative treatment. These include (1) preservation of neurologic function, (2) improvement in neurologic deficit if already present, (3) reduction of spinal deformity and maintenance of acceptable alignment, (4) minimization of loss of spinal mobility, and (5) achievement of a healed and stable spinal column.
At the Scene
According to Advanced Trauma Life Support (ATLS) protocol, life-threatening compromise to airway, breathing, and circulation should be promptly addressed. Although the greatest risk for spinal cord injury occurs at the time of high-energy impact, neurologic deficits can develop thereafter during treatment. In 1983, Podolsky and colleagues reported that up to 25% of spinal cord injuries had been caused by or aggravated after the patient had come under medical care. Immobilization of the injured spine is the key to preventing such catastrophic decline.
The care of spine trauma patients at the scene has dramatically improved over the past several decades. Extrication and transport of trauma patients with immobilization techniques and adherence to ATLS protocols for resuscitation have been credited for this improvement. ATLS protocol mandates that a spine injury be assumed for all injured patients and rigid immobilization employed. At the scene, the patient should be immobilized with a cervical collar, head immobilization device, and spine backboard.
At the Hospital
The patient should arrive in the emergency department on a backboard with a cervical collar in place. In the face of a global instability, motion can still occur in spite of all attempts at rigid immobilization. The patient should be moved on and off the backboard as few times as possible until the stability of the spine can be adequately assessed. For most injuries, the collar provides an increased level of stability. However, it does not provide complete immobilization. With a complete ligamentous disruption, the collar has minimal effect. The person stabilizing the spine is much more significant in restricting motion.
Moving the patient off the backboard for computed tomography (CT) should be coordinated so that imaging of the brain, spine, chest, abdomen, pelvis, sinus, or orbits or any other appropriate study is obtained in one trip to the scanner and one movement off and on the backboard. The risk of decubitus ulceration is directly proportional to the length of time on a backboard—8 hours on a backboard is associated with a 100% likelihood of a decubitus ulcer. The patient should be moved from the board as soon as possible. Appropriate spine immobilization must be continued at all times.
Contrary to all available evidence suggesting that the log roll is an ineffective and potentially dangerous technique for spine immobilization, it is still almost universally used. In fact, studies conducted prior to 2004 showed dramatic and unacceptable motion with a log roll. Since that time, many studies have reevaluated this controversial subject. Compared with any other method of transfer, the log roll maneuver has been shown to cause more segmental motion at the level of the unstable, injured segment. Lift and slide techniques are far superior because they tend to create less motion at the injured segment.
Imaging Studies
Following review of the initial CT scan, another assessment of spinal stability can be performed. When a closed reduction of a dislocated segment is needed, it should be performed expediently in the awake and alert patient. Serial neurologic examinations are performed during such a reduction maneuver. If the patient is obtunded or reliable neurologic examinations are impossible, then an emergent magnetic resonance imaging (MRI) should be obtained prior to attempting reduction to rule out significant disc herniation.
In the absence of a facet dislocation and in the presence of significant spine injury, the appropriateness of an MRI scan must be determined. The spinal motion necessary to transfer the patient on and off the MRI table must be kept in mind when deciding the necessity of this imaging modality. The strongest argument for an MRI is a suspected neurologic deficit that is not explained by the injury seen on the CT scan. The other indication for MRI is for the evaluation of the posterior ligamentous complex, which is felt to be critical for stability of the spinal column at all levels. If the patient has an unstable injury that requires surgery that is identified clinically or by other imaging studies, it is not necessary to obtain an MRI just to assess the dorsal ligamentous complex.
Anteroposterior and lateral radiographs of the cervical, thoracic, lumbar, and sacral spine are standard imaging studies obtained in cases of high-energy impact with suspected spinal injury. Distracting injuries can often mask symptoms secondary to significant spine injury, and meticulous assessment of the spine must always be performed ( Figs. 140-1 to 140-3 ). It is necessary to image the entire spinal column due to a 10% incidence of noncontiguous spinal injuries. Specific injury mechanisms and fracture patterns should prompt the treating team to search for commonly associated nonspinal injuries. Flexion-distraction injuries are highly associated with potentially life-threatening intra-abdominal injuries, so these must be ruled out. Patients with transverse process fractures at L5 have a 61% incidence of a pelvic fracture. Falls from a height with resulting burst fractures are often associated with significant lower-extremity fractures, in particular those of the tibia and calcaneus.
Closed Reduction of the Cervical Spine
Decompression of the spinal cord through closed reduction should be performed as soon as the patient can medically tolerate it. Closed reduction is a means of reducing cervical spine deformity, indirectly decompressing neural elements, and providing stability. It has been shown to be safe and can dramatically improve neurologic status if performed within the first few hours following injury. In animal studies, Carlson and colleagues showed that decompression within 3 hours showed better and quicker neurologic recovery. A small series of patients with no cord function who received reduction in an emergent manner immediately began to recover. Although this is anecdotal, it is extremely important. The timing question is answered after consideration of the risk-benefit ratio between waiting to obtain a prereduction MRI and proceeding directly with reduction.
Considerable controversy surrounds the order of the reduction and obtainment of an MRI in an acute cervical spine dislocation. Eismont and coworkers reported on a series of six patients who roentgenographically demonstrated herniation of an intervertebral disc with marked protrusion of disc material into the spinal canal following subluxation or dislocation of a cervical facet. For the first patient in this series, no myelogram or CT scan was performed, and the patient awoke with complete quadriplegia following dorsal open reduction and internal fixation. Following a myelogram and ventral decompression surgery, the cause was identified as an extruded intervertebral disc. The authors recommended obtaining an MRI in all patients prior to attempted closed reduction and definitive surgery. Several other cases with neurologic deficits after open reduction under general anesthesia have been reported. There have also been reports of progression of neurologic deficits during traction while the patient was awake and participating that later resolved.
The group from Thomas Jefferson University advocates performing immediate closed reduction in the patient who is awake and can reliably participate in serial neurologic examinations. Vaccaro and associates published their series of 11 patients who underwent successful awake closed reduction without any neurologic worsening. In their series, two patients had herniated discs prior to reduction, and another five had herniated discs following reduction. Darsaut and colleagues attempted to determine the effect of disc herniation during closed reduction in a series of 17 patients who had a cervical dislocation that was reduced under MRI monitoring. They demonstrated that at least as a research tool this technique was possible.
A commonly used algorithm is based on the patient’s neurologic status. If the patient is unable to participate reliably in the physical examination, then an MRI is obtained as expediently as possible. The principal disadvantage of obtaining an MRI is the loss of potentially valuable time. If the patient has a significant spinal cord injury, the risk is that the cord will remain compressed for a longer time. Therefore, if the patient has minimal or no neurologic dysfunction, an MRI should be obtained. If the patient has an American Spinal Injury Association (ASIA) A, B, or C injury and is able to cooperate with the reduction and serial neurologic examinations, consideration should be given to an immediate, rapid reduction. In this situation, the MRI would be obtained after reduction. In the setting of an obtunded patient without an accurate examination, an MRI should be obtained prior to attempting any reduction maneuver.
Reduction Techniques
Reduction of a cervical spine dislocation must be performed under image guidance and in a very controlled manner. Gardner-Wells tongs are applied with the pins placed 1 cm above the pinna of the ear just below the equator of the head. Pins are tightened to 3.6 kg of pressure. This is indicated once the precalibrated indicator pins protrude a measured amount. If using weights over 25 kg, titanium pins and MRI-compatible tongs are insufficient. Weights of over 60 kg have been used safely for closed reduction of such injuries. In such instances, stainless steel pins or two sets of tongs must be used. Another option includes the use of a halo that provides four titanium pins to distribute the forces over more pins. The major disadvantage of stainless steel pins is their MRI incompatibility.
It is recommended that the initial applied weight be no more than 4.5 kg. Using more weight can be catastrophic if the patient has an unrecognized instability such as an occipital cervical dislocation. After applying the initial 4.5 kg, a neurologic examination should be performed, followed by a radiograph. Weight should be added incrementally until reduction is obtained. Serial examinations, as well as serial roentgenograms, are performed to look for any neurologic deficit following each addition of weight. After reduction, the weight should be decreased to the minimum needed to maintain the reduction. Routine examinations are continued, as are efforts to stabilize the instability when medically appropriate. Pulmonary and skin issues can be addressed with use of a kinetic treatment table until surgery.
Definitive Treatment
Closed treatment remains the standard of care for most spinal injuries. In a few situations, surgical intervention is clearly required, including skeletal disruption in the presence of a progressive neurologic deficit and purely ligamentous injuries in a skeletally mature patient. Such ligamentous injuries require spinal fusion to obtain stability. It should also be noted that the presence of a neurologic injury is not an absolute indication for surgery. The remaining gamut of spinal injuries can be treated without surgery. Closed treatment options include bed rest, halo apparatus, external orthosis, or a cast. Many injuries can be treated with an initial period of bed rest in a kinetic treatment bed followed by bracing and mobilization once some early healing has been achieved. The absence of significant pain should be the clinical indicator of the patient’s readiness to be cleared from the kinetic treatment bed and mobilized. Upright films in the external orthosis should be obtained to confirm that the spinal column is stable at this point.
Timing of Surgical Intervention
Debate continues over the appropriate timing of traction or surgery in cases of acute spinal cord injury. It is difficult to demonstrate improvement in neurologic function from acute surgical intervention. Complete cord injuries and neurologically intact patients are likely to remain neurologically unchanged with appropriate surgical or nonoperative care. Incomplete lesions typically improve with either surgical or nonsurgical care. Late surgery with decompression of the spinal canal in incomplete cord injuries has been shown to improve neurologic function even several years following the traumatic event. In the acute setting, there has been sparse evidence supporting early surgery, although the (Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated that those undergoing decompression within 24 hours showed a 2.8 times greater likelihood of a 2 grade ASIA Impairment Scale (AIS) improvement as compared to those having late decompression. Surgery for the purpose of spinal canal decompression in a neurologically intact patient is difficult to defend considering that several series have shown dramatic spinal canal remodeling over time in patients with and without surgery.
Upper Cervical Injuries
Occipitocervical injuries are most often fatal and typically found postmortem. When encountering a patient with such an injury, the treating physician must be vigilant about the diagnosis to ensure the patient’s survival. Initially, such patients should be meticulously immobilized on a backboard with a collar and the head secured with sandbags and tape. Atlanto-occipital disassociation is then stabilized with a halo vest until definitive surgical stabilization is performed. It should be noted that traction for type II injuries (axial distraction) can be catastrophic and is strictly contraindicated. The injury is treated with dorsal occipital cervical fusion with at least 3 months of halo vest immobilization. Occipital condyle fractures and Jefferson or atlas ring fractures are typically managed with an orthosis or a halo.
Odontoid fractures depend on the injury itself, and significant controversy remains regarding their management. Many can be treated with a rigid orthosis or halo vest. Type I and type III fractures typically heal uneventfully and have a good prognosis without surgery. Transverse type II fractures through the waist of the odontoid have a high associated nonunion rate and there is much controversy regarding their treatment. A dorsally displaced odontoid fracture is more likely to be treated with surgery. Polin reported on a series of patients treated with a rigid collar as opposed to a halo. More nonunions were associated with the type II fractures. However, there was no statistically significant difference between the orthoses used. Chronic odontoid nonunions in the elderly can at times be followed and may not require surgical intervention. In a series of persistent nonunions, no progression of atlantoaxial instability or neurologic deficit was noted or myelopathic symptoms during the follow-up period. Contrary to this result, Kepler and coworkers observed a 17% incidence of new neurologic deficits in a similar cohort. Each case must be treated on an individual basis and involve decision making by the patient and oftentimes the family involved.
At later reassessment of stability, transverse ligament ruptures can be managed in an orthosis if a bony avulsion occurs. If successful, this avoids the significant loss of motion following an atlantoaxial arthrodesis. Dickman and associates demonstrated a 100% failure to heal in complete ligamentous disruptions. These injuries often result in a significant incidence of neurologic injury, and there is frequent association with other upper cervical injuries. They should be treated with C1-2 arthrodesis.
Most other axis injuries can be stabilized with an orthosis or a halo vest. Traumatic spondylolisthesis of the axis most commonly occurs secondary to a hyperextension and axial load mechanism. Neurologic deficit rarely occurs, with the exception for the atypical fracture that occurs ventral to the dorsal vertebral body cortex. These atypical fractures may require surgery to prevent neurologic decline. Severe hangman’s fractures with instability through the C2-3 disc space require surgery. Most other axis injuries can be managed successfully nonoperatively.
Subaxial Injuries
Isolated minimally displaced subaxial lamina and spinous process fractures can be treated with a cervical collar. Single-level axial compression fractures with intact ligaments can be managed similarly. Minor ventral column injuries due to a flexion-compression mechanism with intact dorsal ligaments should also be stabilized in an orthosis.
The treatment of burst-type fractures is controversial due to how imprecisely mechanical stability is determined. Fractures that are thought to be mechanically stable can be treated nonoperatively but require close follow-up. In the setting of cord compression from retropulsed bone fragments in the neurologically compromised patient, ventral decompression and fusion are clearly indicated. In between is a gray area that certainly requires greater investigation to guide treatment.
In subaxial facet dislocations, the nonoperative management is reduction as soon as medically appropriate. After reduction, surgical stabilization is usually necessary because up to 40% of cases remain unstable even after 3 months of halo immobilization.
Hyperextension injuries are common after falls in the elderly and can result in spinal cord injury in the absence of mechanical instability. The resulting central cord syndrome results from neural compression due to narrowing of the canal from long-standing spondylosis and the hyperextended position at impact. Surgery is not performed to address instability but may be utilized to decompress the cord or to prevent further injury. A collar may be placed acutely for patient comfort.
Table 140-1 summarizes the treatment options for cervical fractures.
| Cervical Injuries | Observation | Collar | Halo | Surgery |
|---|---|---|---|---|
| Atlanto-occipital dissociation | √ | |||
| Jefferson fracture—stable | √ | √ | ||
| Jefferson fracture—unstable | √ | √ | ||
| Axis body fracture | √ | √ | ||
| Type I odontoid fracture | √ | √ | ||
| Type II odontoid fracture | √ | √ | √ | |
| Type III odontoid fracture | √ | √ | ||
| Unilateral facet dislocation | √ | |||
| Bilateral facet dislocation | √ | |||
| Subaxial compression fracture | √ | √ | ||
| Unilateral facet fracture | √ | √ | √ | |
| Spinous process fracture | √ | √ |
Thoracic and Thoracolumbar Fractures
Transverse process fractures that are isolated require no treatment and can be mobilized as tolerated. With multiple transverse process fractures, a thorough assessment must be made to determine instability or a fracture-dislocation. An L5 transverse process fracture has a 61% association with a pelvic or sacral fracture. These should be critically evaluated with a pelvic CT scan to rule out an associated pelvic injury.
Compression fractures without injury to the dorsal ligamentous complex can be mobilized as tolerated with an orthosis for comfort. Ohana and coworkers have even suggested that an orthosis may not be necessary. A level 1 study has also shown that braces do not improve outcomes (ODI), pain scores, or deformity in those with osteoporotic compression fractures. Multiple-level compression fractures in a young healthy individual suggest a high-energy mechanism. Particular attention must be paid to the dorsal ligamentous complex at all injured levels. If a dorsal ligamentous injury is present, surgical treatment is necessary.
Burst Fractures
Most lumbar and thoracolumbar burst fractures can be managed nonsurgically ( Table 140-2 ). Several excellent studies have shown comparable functional outcome to surgery, with less morbidity from nonsurgical treatment. The key to establishing stability is the intact dorsal ligamentous complex. Wood and colleagues demonstrated in a prospective, randomized series comparable or better outcomes in the nonoperative group as compared to those patients treated surgically. Although Denis and associates in 1984 reported a 17% increase in neurologic deficit with nonoperative treatment, this has not since been reported. There are multiple reports with minimal complications and almost no progression of neurologic deficits. There appears to be little correlation to long-term pain and disability with degree of kyphosis.
Related posts:
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Diffuse Idiopathic Skeletal Hyperostosis
Spinal Dural and Extradural Vascular Malformations
Spinal Wound Closure
Explant Analysis of Wear, Degradation, and Fatigue in Motion Preserving Spinal Implants
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